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A middle aged women consulting online about menopause.

New Patient Information Form

Regular GP

(Ask Your Gp If Unsure Of These)

Have you ever had:

If you ticked any of these please put details under "Medical Conditions", above.

Menopause Symptom score
SEVERITY IS SCORED AS FOLLOWS: None=0; Mild=1; Moderate=2; Severe=3
1 Hot flushes/ night sweats
2 Headaches
3 Light headed feelings
4 Irritability
5 Depression
6 Unloved feelings
7 Anxiety
8 Mood changes
9 Sleep disturbance
10 Unusual tiredness
11 Back ache
12 Joint pains
13 Muscle pains
14 New facial hair
15 Dry skin
16 Crawling feelings under skin
17 Less sexual feelings
18 Dry vagina
19 Uncomfortable intercourse
20 Urinary frequency
Terms and Conditions

I understand that my email address will be added to the WellFemme mailing list to receive monthly newsletters, and that I can opt out from this at any time.

I understand that telehealth is the use of electronic information and communication technologies by a healthcare provider to deliver services to an individual who is at a different location, and I consent to WellFemme providing health care services to me via telehealth.

I understand that the benefits of a telemedicine consultation are that I do not need to physically travel to the consultation location and I have access to specialised care which may not otherwise be easily available.

I understand that the Australian privacy laws which apply to the privacy and confidentiality of medical information also apply to telehealth.

I understand that I will be responsible for fees that apply to my telehealth consultation, to be paid 2 days prior to the scheduled appointment, and that no Medicare rebate is claimable. I also understand that booking changes may be made prior to the day of consultation without charge. Cancellations 12-24 hours prior will be charged a $20 fee, 2-12 hours prior incurs a $50 fee and there is no refund for cancellations within 2 hours of appointment time.

In cases where this Telehealth service attracts a Medicare rebate which is to be bulk-billed, I assign my right to benefits to the practitioner who has rendered the service (as per Department of Human Services form DB4E- Bulk Bill voucher).

I understand that I have the right to withhold or withdraw my consent to the use of telehealth at any time either verbally or in writing, without affecting my right to future care or treatment.

I understand that WellFemme does not routinely record telehealth consultations and does not authorise patients to make their own recordings of telehealth consultations. If either party has a reason for wishing to do so this must be verbally agreed beforehand and recorded in my medical notes by the clinician.

I understand there are potential risks with telehealth consultations:
1. The video connection may not work or may stop working during the consultation, or
2. The image or audio transmitted may not be clear enough to facilitate the consultation. In either case I will have the option to complete the consultation by telephone, reschedule, cancel with full refund or make other arrangements with WellFemme.
3. Telehealth limits a practitioner’s ability to perform physical examinations, so I may be directed to see a medical practitioner in person if the telehealth doctor believes it necessary for my medical care.
WellFemme will take reasonable steps to mitigate these risks and protect the information sent and received but the security and confidentiality of all communications cannot be guaranteed.

I understand that my medical information will only be stored on secure, cloud-based medical software and will not be held on any insecure website or computer elsewhere.

I understand that WellFemme will use secure email or document transfer systems to convey information to me, but that the receipt and handling of that information by me is my own responsibility. If my email service is insecure it may potentially allow unauthorised access to information received and sent by me.

I understand that WellFemme is not a General Practice, and its scope of practice is strictly limited to my clinical needs related to Menopause. WellFemme doctors will not treat or advise on any unrelated medical conditions.

I also understand that WellFemme may share information with my regular doctor/s and the Australian e-Health record system with my consent, but that I can withhold or withdraw that consent and/or choose which information is shared.

I understand that my email address will be added to the WellFemme mailing list to receive monthly newsletters, and that I can opt out from this at any time.

(Must tick acceptance to proceed)